Immunizations

Vaccine
A suspension of attenuated live or killed
microorganisms administered to induce immunity

Toxoid
A modified bacterial toxin, now nontoxic, which
stimulates formation of antitoxins

Active immunity
Results when an antibody is produced in
response to a vaccine or toxoid
Passive immunity
Occurs when performed antibodies are given,
resulting in temporary immunity

Herd immunity
Results when enough persons are immunized to
prevent transmission of disease to unimmunized
persons
 Live attenuated
Viral MMR, varicella, yellow fever, polio
Bacteria (OPV)
BCG, oral typhoid
Inactivated
Whole Virus Polio, rabies, hepatitis A
Fractional Protein Subunit: hepatitis B, influenza,
based acellular pertussis
Toxoid: diphtheria, tetanus
Pure: pneumococcal, Hib,
Composition of vaccines
•All vaccines containing an adjuvant must be
administered intramuscularly. Such injections
given at a 90ο angle into the anterolateral thigh
(not intragluteally) in infants (< age 18 months)
and may be given in the deltoid or triceps in older
children

•Subcutaneous injections given at a 45ο angle into

the anterolateral aspect of the thigh or the upper
outer triceps area

•Intradermal injections given on the volar surface

of the forearm with the bevel facing upward using
a ⅜–¾ inch 25- to 27-gauge needle
Simultaneous administration of vaccines

•Inactivated vaccines may be given

simultaneously at separate sites, except cholera,
typhoid, and plague

•Live virus vaccines given on different days

should be administered 1 month apart

•Pneumococcal polysaccharide and whole virus

influenza can be given simultaneously, at
different sites
If an immunoglobulin (Ig) or blood product has
been administered, live-virus vaccination should
be delayed 3–11 months to avoid interference
with the immune response:
•3 months for tetanus Ig, hepatitis A Ig, and
hepatitis B Ig,
•5–6 months for measles Ig or cytomegalovirus Ig
(CMVIg), and
•11 months for intravenous Ig for Kawasaki
disease
Hypersensitivity

•Avoid it

•Egg hypersensitivity can occur with influenza

and yellow fever vaccines

•Neomycin is contained in IPV , measles,

mumps, rubella, and MMR

•Streptomycin is contained in IPV and MMR

Contraindications and Precautions

Contraindications to vaccines

•Permanent
Severe allergy to a prior dose of vaccine or to a
component

•Temporary
Pregnancy and immunosuppression – vaccine
deferral as indicated
Misconceptions

The following are not contraindications to

immunizations
•A reaction to a previous DPT of temperature
< 105ο F, redness, soreness and swelling
•A mild, acute illness in an otherwise well child
•Concurrent antimicrobial therapy
•Prematurity – immunize at the chronological age
•A family history of seizures
• A family history of sudden infant death
syndrome
Immunizations in special circumstances

•Immunocompromised
No live virus vaccine
But poor response to inactivated

•Preterm infants
Immunize at chronologic age
Do not reduce dosage
•Vaccines against seven diseases are currently
recommended by the EPI for routine use in the
developing world

•BCG, DTP, OPV, measles, and hepatitis B

vaccines for children and
tetanus toxoid for pregnant women

•Hib, Yellow fever, Japanese encephalitis, group

A meningococcus, mumps, and rubella vaccines
are used regionally, depending on the disease
epidemiology and resources
Expanded program on immunization (EPI)

•Routine immunization schedule comprises 7 vaccine

preventable diseases, namely tuberculosis, polio,
diphtheria, pertussis, tetanus, measles, and hepatitis B

•Before the age of one year, the routine immunization

schedule should be completed by all children

•Women of childbearing age are given tetanus toxoid

vaccine to protect their unborn babies from tetanus

•The mothers and their future babies obtain full

protection after completing the TT schedule
 Routine immunization schedule
(developing countries)
Vaccine Diseases Age
BCG Tuberculosis At birth
DPT Diphteria, 6, 10, 14 weeks
Pertussis,
Tetanus
OPV Polio (At birth), 6, 10, 14 weeks
Measles Measles 9 months
HepB Hepatitis B 0, 1, 6 months (6, 10, 14
weeks)
Schedule for Tetanus Toxoid administration

Dose Time for administration Duration of protection

TT1 At first contact No protection

TT2 4 weeks after TT1 Three years
TT3 At least 6 months after TT2 Five years
TT4 At least one year after TT3 Ten years
TT5 At least one year after TT4 For thirty years
(throughout a woman’s
reproductive life)
 Childhood Immunization Schedule (US)
Age Immunizations

Birth HBV (1)

2mo HBV(2) DTaP (1) Hib (1) IPV(1) PCV(1)
4mo DTaP (2) Hib (2) IPV(2) PCV(2)
6mo. DTaP (3) Hib (3) PCV(3)
6-18 mo HBV(3) IPV(3)
12-15mo Hib(4) PCV(4) MMR(1)
> 12 mo Varicella
15-18mo DTaP (4)
4-6 yr DTaP (S) IPV(4) MMR(2)

•Influenza vaccine recommended annually for children

aged 6 months to 24 months and for all children >6
months with chronic pulmonary, cardiovascular,
metabolic, or sickle cell disease
•Tetanus-diphtheria vaccine is given at age 11 years and
then every 10 years thereafter
General rules for catch-up vaccines
For lapsed vaccines,
•resume schedule as if usual interval has elapsed
•do not repeat doses of HiB
•PCV 7 not needed again if immunocompetent
child is >= 5 years old

•Second-dose HiB indicated only if first dose is

given >15 months of age
•Second-dose PCV 7 only if child >2 years
•If unsure and no proof of immunizations, assume
none and vaccine from beginning
Lapses in the immunization schedule do not call
for reinstitution of the series

•Extra doses of hepatitis B (HepB), Haemophilus

influenzae type B (Hib), MMR, or VAR are not
harmful

•Repetitive exposure to tetanus vaccine beyond

the recommended intervals can result in
hypersensitivity reactions and should be avoided
Immunization recommendations for HIV infection
Bacille Calmette-Guérin vaccine (BCG)
•consists of live attenuated Mycobacterium bovis
•inexpensive, can be given any time after birth
•sensitizes the vaccinated individual for 5–50 yrs
•stimulates both B-cell and T-cell immune
responses

•BCG reduces the risk of tuberculous meningitis

and disseminated TB in pediatric populations by
50–100% when administered in the first month of
life.
Adverse effects
•occur in 1–10% of healthy individuals,
•local ulceration, regional lymph node
enlargement, and lupus vulgaris.

Contraindication
•pregnant women
•immunocompromised individuals, including
those with HIV infection
Interpretation of Tuberculin Skin Test
(Mantoux test) Reactions
Risk Factors Positive
Reaction
Recent close contact with a case of active 5 mm
tuberculosis; chest x-ray compatible with induration
tuberculosis; immunocompromise; HIV
infection

•Current or previous residence in high- 10 mm

prevalence area (Asia, Africa, Latin America); induration
•skin test converters within past 2 years;
•intravenous drug use;
•homelessness or residence in a correctional
institution;
•recent weight loss or malnutrition;
•leukemia, Hodgkin disease, diabetes mellitus;
•age < 4 years
Positive induration reaction in Mantoux test
•5-mm or greater cutoff for a positive Mantoux
test is used in immunocompromised children.

•Cutoff is 10 mm or above in immunocompetent

persons

•Cutoff is 15 mm or above when no risk factors

are present in the absence of clinical disease
(eg, screening).
Strongly positive Mantoux test in a patient with active tuberculosis.
Intradermal injection of M. tuberculosis antigen has induced a
florid type IV hypersensitivity reaction with some blistering.
Factors associated with increased probability that
a positive TB skin test is due to
M tuberculosis infection include
(1) larger reactions,
(2) contact with an individual known to be infected,
(3) family history of TB,
(4) longer interval between BCG administration
and skin testing, and
(5) country of origin with increased incidence of
endemic TB.
•BCG almost invariably causes its recipients to
be tuberculin-positive (5–7 mm)

•Reaction often becomes negative after 3–5

years

•A positive Mantoux test in a child with a history

of BCG vaccination who is being investigated for
TB as a case contact should be interpreted as
indicating infection with M tuberculosis.
Polio Eradication Initiative
One of a small limited number of diseases that
can be eradicated
Reasons why polio can be eradicated are:
- polio only affects humans, and there is no
animal reservoir
- an effective and inexpensive vaccine exists,
called Oral PolioVirus (OPV)
- immunity against polio is life-long
- the virus can only survive for a very short time
in the environment
•Injectable
•Killed polio vaccine (Inactivated)
•Incapable of causing poliomyelitis (whereas
OPV can do so rarely)

•Contraindication
•Anaphylaxis to neomycin or streptomycin
DTaP

Common side effects

•fever up to 105o F in the first 24 h, redness, or
swelling and soreness at the injection site

Less common side effects

•Inconsolable crying for > 3 h, temperature >105o
F, and a high- pitched cry
•Rarely, seizures occur, probably from the fever
•No evidence to date that the pertussis vaccine
causes brain damage
DTaP
Contraindication
•serious CNS problem within 7 days of receiving the
vaccine,
•anaphylactic reaction,
•unstable encephalopathy

In those cases, DT should be substituted

Acetaminophen reduce the discomfort of the side

effects

In patients with prior history of pertussis, the

pertussis component may be left out of subsequent
vaccines
Common sided effects of the MMR include
sore arm for 1-2 days
Most effects occur 1-2 weeks after immunization

Measles
Rash,
fever,
upper respiratory infection symptoms

Mumps
Slight salivary gland swelling
Rubella
Cervical lymph adenopathies
Arthralgia

All the vaccines can cause febrile seizures and

reversible encephalopathy

MMR should be delayed for

•Pregnancy or possibility of pregnancy
•Anything more than a minor illness, and
•Patient receiving gammglobulin in the past 3
months
Contraindications

•Anaphylaxis to any of its components

•Immunodeficiency
(such as cancer, leukemia, severe HIV
immunosuppression, radiation therapy,
chemotherapy, and steroids)
HiB

Side effects
•Local swelling and low-grade fever
•Invasive HiB disease under 2 years of age does
not confer immunity, and the patient still requires
immunization

•One dose of HiB given after 15 months of age

confers immunity, and there is no need to give
the entire series
•Pneumococcal vaccine recommended for all
children beginning at 2 months of age
•A heptavalent conjugated vaccine used

•All children >2 years of age with sickle cell

anemia, functional or anatomic asplenia, and
immunosuppression should receive
pneumococcal vaccine (23 valent)
•Now universally recommended

•Patients born to hepatitis B surface antigen-

negative mothers receive vaccine in the usual
time schedule

•Patients born to hepatitis B surface antigen-

positive mothers also require hepatitis B immune
globulin along with the first dose of vaccine
Perinatal transmission

If mother is HBsAg+ and HbeAg:

•70 – 90% infants infected
•90% infected become carriers

If mother only HBsAg+:

•20% infants infected
•90% infants become carriers
Prevention of Perinatal HBV infection
•Begin prevention within 12 h of birth
•HBV and HBIG at different sites
•85 – 95% successful

Adolescent HBV alternative

•Two-dose adolescent schedule (11 – 15 years)
separated by 4 – 6 months
•Does not cover all serogroups
•Active immunization against serotypes A, C, Y,
and W-125
•Not protective for those <2 years of age
MCV4 is the preferred vaccine for people 11-55 years
and should be given to:
•All adolescents at their11-12 yr health maintenance visit
•All adolescents as they enter high school if not
previously immunized
•Other adolescents who want to decrease their risk of
meningococcal disease
•Microbiologists
•Military recruits
•People living in or traveling to areas where
meningococcus is endemic
•People with a damaged spleen or asplenia
•People with terminal complement deficiency
•People exposed during a meningococcal outbreak
•Live attenuated vaccine scheduled for all
children 12 – 18 months of age and all children
without a history of varicella

•Patients aged 12 months to 12 years have a

95% seroconversion rate

•Children younger than 12 years of age receiving

the vaccine require two doses at least 4 to 8
weeks apart for effective seroconversion
•The vaccine is 100% protective against severe
disease

•Breakthrough infections can occur that may

result in mild disease

•Mild varicella with <50 lesions may still be

contagious
Postexposure prophylaxis with VZIG:
•Newborn and mother – 5 days prior to delivery to
2 days after
•Susceptible pregnant women
•Immune deficiency
•Hospitalized preterm infant born at < 28 weeks
or weighs < 1000 grams
Contraindications

•Moderate to severe acute illness

•Malignancy or T-cell defect, including HIV
infected with CD4 counts <25%
•High – dose steroid treatment
•Pregnancy
•Component allergy
•Inactivated vaccine produced in embryonated
eggs
•Duration of immunity is <1 year
•Schedule 1 dose annually
•Avoid the flu shot in patients with egg
anaphylaxis
•Consider live attenuated intranasal influenza
vaccine
Recommendations

•All persons >50 years

•Infants 6 – 23 months
•Persons > 6 months with chronic illness
•Pregnant women – at least 14 weeks
•Those 6 months to 18 years receiving salicylates
•Split dose <9 years old
Guide to Contraindications and Precautions to
Commonly Used Vaccines.
Vaccine True Contraindications
and Precautions
General for all vaccines, including Contraindications 
diphtheria and tetanus toxoids and Serious allergic
acellular pertussis vaccine (DTaP); reaction (eg,
pediatric diphtheria-tetanus toxoid anaphylaxis) after a
(DT); adult tetanus-diphtheria previous vaccine dose
toxoid (Td); inactivated poliovirus Serious allergic
vaccine (IPV); measles-mumps- reaction (eg,
rubella vaccine (MMR); anaphylaxis) to a
Haemophilus influenzae type b vaccine component
vaccine (Hib); hepatitis A vaccine; Precautions 
hepatitis B vaccine; varicella Moderate or severe
vaccine; pneumococcal conjugate acute illness with or
vaccine (PCV); influenza vaccine; without fever
and pneumococcal polysaccharide
DTaP Contraindications 

Severe allergic reaction after a previous dose or to a

vaccine component
Encephalopathy (eg, coma, decreased level of
consciousness; prolonged seizures) within 7 days of
administration of previous dose of DTP or DTaP
Progressive neurologic disorder, including infantile spasms,
uncontrolled epilepsy, progressive encephalopathy: defer
DTaP until neurologic status clarified and stabilized.
Precautions 
Fever of > 40.5 °C 48 h after vaccination with a previous
dose of DTP or DTaP
Collapse or shock-like state (ie, hypotonic hyporesponsive
episode) 48 h after receiving a previous dose of DTP/DTaP
Seizure 3 d of receiving a previous dose of DTP/DTaP
 
Persistent, inconsolable crying lasting 3 h 48 hours after
receiving a previous dose of DTP/DTaP
Moderate or severe acute illness with or without fever
DT, Td Contraindications  —
Severe allergic reaction after a previous dose or to  
a vaccine component
Precautions 
Guillain-Barré syndrome 6 wk after previous dose of
tetanus toxoid-containing vaccine
Moderate or severe acute illness with or without
fever
IPV Contraindications 
Severe allergic reaction to previous dose
or vaccine component
Precautions 
Pregnancy
Moderate or severe acute illness with or
without fever
MMR Contraindications 
  Severe allergic reaction after a previous dose or to a
vaccine component
Pregnancy
Known severe immunodeficiency (eg, hematologic
and solid tumors; congenital immunodeficiency; long-
term immunosuppressive therapy,or severely
symptomatic human immunodeficiency virus [HIV]
infection)
 
Precautions 
Recent ( 11 mo) receipt of antibody-containing blood
product (specific interval depends on product)
 
History of thrombocytopenia or thrombocytopenic
purpura
Moderate or severe acute illness with or without
Hib Contraindications 
Severe allergic reaction after a previous dose
or to a vaccine component
Age < 6 wk
Precaution 
Moderate or severe acute illness with or
without fever
Hepatitis Contraindication 
B Severe allergic reaction to yeast, to any vaccine
component, or after a previous dose
Precautions 
Infant weighing < 2000 g 
Moderate or severe acute illness with or without
fever
Hepatitis Contraindications 
A Severe allergic reaction after a previous dose or
to a vaccine component
Precautions 
Pregnancy
Moderate or severe acute illness with or without
fever
Varicell Contraindications 
a Severe allergic reaction after a previous dose or to
  a vaccine component
Substantial suppression of cellular immunity
Pregnancy
Precautions 
Recent ( 11 mo) receipt of antibody-containing
blood product (specific interval depends on
product) 
Moderate or severe acute illness with or without
fever
PCV Contraindication 
Severe allergic reaction after a previous dose
or to a vaccine component
Precautions 
Moderate or severe acute illness with or
without fever
Meningococ Contraindications 
cal (MCV4) Severe allergic reaction to any vaccine
component, including diphtheria toxoid, or to
dry natural rubber latex
Pregnancy
Precautions 
Prior history of Guillain-Barré syndrome
Moderate or severe acute illness with or
without fever
Influenza Contraindication 
Severe allergic reaction to previous dose or
vaccine component, including egg protein